9.8 Prostate cancer
Age 0-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-79 >80
Screening for prostate cancer is not recommended unless:
1. the man specifically asks for it; and
2. he is fully counselled on the pros and cons
Routine screening for prostate cancer with DRE, PSA or transabdominal ultrasound is not recommended.548-550 DRE has poor ability to detect prostate disease.551 Yet some cancers missed by PSA testing alone are detected by DRE,551 which is why those recommending screening advocate DRE as well as PSA.
The recommendation is contentious. Two large RCTs552,553 found none or marginal benefit. However, analysis of the data from one centre contributing to one of these554 showed an increased survival from prostate cancer (but not mortality from any cause) beyond 10 years. Two recent systematic reviews concluded that screening is not effective.555,556
Even if we were to conclude there was a survival benefit (from current or future trial data), this survival would need to be balanced against the harms of cancer overdetection and treatment.
GPs need not raise this issue, but if men ask about prostate screening they need to be fully informed of the potential benefits, risks and uncertainties of prostate cancer testing.556 When a patient chooses screening, both PSA and DRE should be performed.
Table 9.8.1 Prostate cancer: identifying risk
|Who is at risk?||What should be done?||How often?|
- The risk of developing prostate cancer increases with age and positive family history. However, because prostate cancer is normally slow growing, men older than age 75 years or with a life expectancy of less than 10 years are at reduced threat of dying from a diagnosis of prostate cancer.
- Men with uncomplicated lower urinary tract symptoms (LUTS) do not appear to have an increased risk of prostate cancer. The most common cause of LUTS is benign prostate enlargement. Early prostate cancer often does not have symptoms.
|Respond to requests for screening by informing patients of risks and benefits of screening (I,A)
||On demand 557-559
- Men with one or more first-degree relatives diagnosed under age 65 years
- Men with a first-degree relative with familial breast cancer (BRCA1 or BRCA2)
|Respond to requests for screening by informing patients of risks and benefits of screening (Practice Point)
||On demand 558-560
Table 9.8.2 Screening for prostate cancer
||The most common adverse effect of radical prostatectomy is erectile dysfunction, which affects most men (it is less common in younger men, those with a lower PSA, and when nerve-sparing surgical techniques are used).548-550,555,561
Other complications are common as well, including urinary incontinence (which is very common in the months after treatment, but returns to normal in 75–90% men after 2 years, depending on treatment type), and to a lesser extent, urinary irritation and bowel symptoms. General feelings of ‘vitality’ are lost in about 10% of men.562
Both suicide and CVD increase enormously (8 and 11 times more, respectively) in the week after men are given their diagnosis of prostate cancer.563
Even diagnostic procedures following positive screening are harmful, with Australian data showing that the risk of life-threatening sepsis needing intensive care admission is not uncommon after biopsy.564
Despite large trials, their meta-analysis suggests that prostate cancer screening does not save lives.555,556
Patients who request testing should be informed about the risks and benefits of tests for prostate cancer, and assisted to make their own decision.565 Written material, particularly decision aids, may be useful for this purpose: see the RACGP green book and a free book providing a balanced presentation of facts566 at http://ses.library.usyd.edu.au/ bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf
Responding to the patient’s concerns and fulfilling medico-legal responsibilities are considerations in discussion with patients.
- US Preventive Services Task Force. Screening for prostate cancer: US Preventive Services Task Force Recommendation Statement. Ann Intern Med 2008;149(3):185–91
- Lim LS, Sherin K, ACPM Prevention Practice Committee. Screening for prostate cancer in US men: ACPM position statement on preventive practice. Am J Prev Med 2008;34(2):164–70
- Ilic D, O’Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane Database Syst Rev 2006;3:CD004720
- Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. Ann Intern Med 1997;126(5):394–406
- Andriole GL, Crawford ED, Grubb RL, 3rd, Buys SS, Chia D, Church TR, et al. Mortality results from a randomized prostate-cancer screening trial. New Engl J Med 2009;360(13):1310–9
- Schroder FH, Hugosson J, Roobol MJ, Tammela TLJ, Ciatto S, Nelen V, et al. Screening and prostate-cancer mortality in a randomized European study. New Engl J Med 2009;360(13):1320–8
- Hugosson J, Carlsson S, Aus G, Bergdahl S, Khatami A, Lodding P, et al. Mortality results from the Göteborg randomised population-based prostate-cancer screening trial. Lancet Oncol 2010;11(8):725–32
- Ilic D, O’Connor D, Green S, Wilt TJ. Screening for prostate cancer: an updated Cochrane systematic review. BJU Int 2011;107(6):882–91
- Djulbegovic M, Beyth RJ, Neuberger MM, Stoffs TL, Vieweg J, Djulbegovic B, et al. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ (Clinical Research Ed) 2010;341:c4543
- National Health and Medical Research Council. Clinical practice guidelines for the management of uncomplicated lower urinary tract symptoms in men. Canberra: NHMRC, 1997
- Bruner DW, Moore D, Parlanti A, Dorgan J, Engstron P. Relative risk of prostate cancer for men with affected relatives: systematic review and meta-analysis. Int J Cancer 2003;107(5):797–803
- Johns LE, Houlston RS. A systematic review and meta-analysis of familial prostate cancer risk. BJU Int 2003;91(9):789–94
- Zeegers MP, Jellema A, Ostrer H. Empiric risk of prostate carcinoma for relatives of patients with prostate carcinoma: a meta-analysis. Cancer 2003;97(8):1894–903
- Alemozaffar M, Regan MM, Cooperberg MR, Wei JT, Michalski JM, Sandler HM, et al. Prediction of erectile function following treatment for prostate cancer. JAMA 2011;306(11):1204–14
- Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med 2008;358(12):1250–61
- Fall K, Fang F, Mucci LA, Ye W, Andrén O, Johansson J-E, et al. Immediate risk for cardiovascular events and suicide following a prostate cancer diagnosis: prospective cohort study. PLoS Med 2009;6(12):e1000197
- Bowden FJ, Roberts J, Collignon PJ. Prostate cancer screening and bacteraemia (letter). Med J Aust 2008;188(1):60
- Gattellari M, Ward J. Does evidence-based information about screening for prostate cancer enhance consumer decision-making? A randomised controlled trial. J Med Screen 2003;10(1):27–39
- Chapman S, Barratt A, Stockler M. Let sleeping dogs lie? What men should know before getting tested for prostate cancer. Sydney: Sydney University Press, 2010 [accessed 2012 June]. Available at ses.library.usyd.edu.au/bitstream/2123/6835/3/Let-sleeping-dogs-lie.pdf